Synopsis While in Johnstone Strait en route from Vancouver to Kitimat, British Columbia, via the inside passage, the RAVEN ARROW ran aground in Boat Bay on the south side of West Cracroft Island when the pilot, who had the conduct of the vessel, ordered an alteration of course. The Board determined that the RAVEN ARROW grounded in fog when the pilot lost situational awareness and prematurely altered course to enter Blackney Passage after having elected to conduct the navigation of the vessel without assistance from the ship's complement. Contributing to the occurrence were the following factors: the pilot was probably fatigued; sound navigational principles were not implemented by the bridge team; the exchange of information between the pilot and the officer of the watch was minimal and imprecise; and the officer of the watch did not effectively monitor the pilot's communication with Marine Communications and Traffic Services. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The vessel is a forest product carrier, with the bridge, accommodation and engine-room aft of the five cargo holds. She is fitted with two gantry cranes. Figure 1 - Sketch of the occurrence area 1.2 History of the Voyage At 1300 Pacific daylight saving time (PDT) on 23 September 1997 the partly loaded RAVEN ARROW departed Vancouver, bound for Kitimat, B.C., with two B.C. coast pilots on board.[3] Pilots alternate their shifts while on board. Pilot No. 1 had the conduct of the vessel upon departure at 1300 until 1800, and pilot No. 2 from 1800 to 2300. The voyage until Johnstone Strait was uneventful, but the pilot was occupied with concentrations of fishing vessels encountered. The pilot exchange took place at 2300, with the vessel off Knox Bay in position 5022.5' N, 12536.8' W, in Johnstone Strait. After the change in watches at 0000, September 24, personnel on the bridge comprised the second officer, who was the officer of the watch (OOW), pilot No.1, who had the conduct of the vessel, and the quartermaster, who was at the helm, engaged in steering. At 0002 the pilot reported to Marine Communications and Traffic Services (MCTS) Vancouver that the vessel was around Fanny Island and her estimated time of arrival (ETA) at Boat Bay Light was 0135. MCTS advised the vessel of the upcoming traffic. In the vicinity of Stimpson Reef the visibility was good as the vessel encountered traffic, including a few fishing vessels. On passing Broken Island, at the eastern end of West Cracroft Island, the vessel's course was altered to 274, to head for a point some 0.5 nautical mile (M) off Boat Bay Light. At 0100, Broken Island Light bore 058, distance 1.9 M, and around this time the vessel began to experience a slight haze. Targets were picked up on the vessel's radar on the 12-mile range. Approaching Forward Bay, the vessel entered fog. By 0120-0125 the visibility had decreased to about 150m and the master was not informed. No dedicated look-out was posted. Between 0100 and 0130 the vessel encountered traffic (for which primarily port-to-port passing arrangements were made); some of which were MCTS participants, while others were not. At 0103 a port-to-port passing arrangement was made with the CAPE PINE, for which a course alteration of some 20 degrees to starboard was carried out (between 0104 and 0107). Upon clearing the CAPE PINE, port-to-port passing arrangements were made with two other fishing vessels. At 0113 a report was made to MCTS that the vessel was off Boat Bay Light and that her ETA at Lizard Point was 0240. The last position, as plotted on the chart by the OOW, was at 0115: 5030.2' N, 12626.32' W, some 5.5 M east of Boat Bay Light. Between the 0045 and 0115 positions the average speed of the vessel was 14.92 knots (kn). At approximately 0130 the pilot saw on the radar what he believed was the entrance to Blackney Passage and commenced a course alteration to starboard. He did not verify the vessel's position prior to the course alteration nor did he request the OOW to plot the vessel's position. Shortly after reaching the new heading of 320, the pilot realized that the vessel was not at the alter-course position and ordered hard-a-starboard helm, in the hopes of bringing her around, but this was unsuccessful and the vessel grounded in position 5031.4' N, 12632.4' W, on a heading of 056. The time of the grounding as recorded in the log books was 0133, while the course recorder trace showed that the grounding occurred at 0136. 1.2.1 Events Following the Grounding At 0138 the pilot reported the grounding to MCTS. The grounding position was initially reported to be off Cracroft Point in Blackney Passage. The master, who had retired to his cabin, was alerted by the grounding. He immediately proceeded to the bridge to assess the situation. The vessel's position was plotted and a revised and accurate grounding position was reported. MCTS issued an advisory requesting all vessels transiting that area to proceed with caution. The crew were called and tank and hold soundings were taken. Depth soundings were also taken in the area of the grounding and it was found that the bow was firmly aground and the stern was afloat in deeper waters. After determining that it was safe to refloat the vessel, the ballast was redistributed and with the assistance of three tugs the vessel was refloated some eight hours later, at 0930. 1.3 Injuries to Persons 1.4 Damage to the Vessel The vessel sustained extensive damage to the shell plating and internals in way of the stem to the No. 3 double-bottom tanks, but there was no pollution. 1.5 Certification 1.5.1 Vessel The vessel was crewed, equipped and operated in accordance with existing regulations. The vessel was in the process of obtaining International Ship Management (ISM) certification. The system was introduced on board in February 1997; the vessel was due for internal and external audits about two months after the occurrence. 1.5.2 Personnel The master held a Master Foreign Going Certificate of Competency, which carried an International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) endorsement and a Global Maritime Distress Safety System (GMDSS) General Operator's Certificate. The second officer was in possession of a Second Mate Foreign Going Certificate of Competency, which carried an STCW endorsement and a tanker (Tankerman [Petroleum] Person-in-Charge) endorsement. He also held a GMDSS General Operator's Certificate. The quartermaster on duty at the time of the occurrence held an Able Seaman/Helmsman Certificate, which carried an STCW endorsement. Pilot No. 1 held an Ocean Navigator 1 (ON1) Certificate of Competency, issued in February 1991. He had completed a six-month apprenticeship period and, like all British Columbia Coast Pilots (BCCP) pilots, he had received ship-handling training at a facility in France and had been to a ship-handling simulator in Rhode Island, U.S.A. Recently, he had received bridge resource management (BRM) training specifically designed for pilots. He had received a Class I Pilotage License issued by the Pacific Pilotage Authority (PPA) in June 1997. 1.6 Personnel History The master has some twenty years' sea service. He had served as a master since 1990 and with the owners since 1994. The second officer had some eleven years' experience as an officer, of which eight years were as a second officer, during which period he had served on very large crude carriers (VLCCs), bulk carriers, and tankers. This was his first vessel with this company and he had joined the vessel on September 17, seven days before the occurrence. He was conducting his first inside passage routing of the B.C. coast. The quartermaster on duty at the time of the occurrence had some twenty years' sea service, of which the last seven years were as a helmsman. Pilot No.1 joined the Department of Fisheries and Oceans in the early 1980s and had served on their vessels for some seven years. He then served in the towing and fishing industry and on the fast ferry in Kitimat before joining the pilotage services. 1.7 Weather, Current and Geographical Information 1.7.1 Weather--Forecast and Experienced The weather experienced by the vessel was consistent with the marine weather forecast for the area. Winds were light and seas calm. Between 0120 and 0125 fog rolled in and the visibility at the time of the grounding was reported to have been about 150m. 1.7.2 Current Information The current and tidal information for the Johnstone Strait area is contained in the Tide and Current Tables, Vol 6. The tidal differences are referenced to Port Harvey and the secondary current stations referenced in the Johnstone Strait are given for Forward Bay. On September 23 high water was at 1921, with a height of 3.93 m (13.0 ft) above chart datum and low water was at 0236, September 24, with a height of 1.48 m (4.9 ft) above chart datum. The flood was weak and variable (general direction of 100). The ebb was 280, reaching a maximum velocity of 1.0 kn at 0200. The current was ebbing and the rate was about 1.0 kn at the time of the occurrence.[4] 1.7.3 Geographical Information Johnstone Strait extends along the NE coast of Vancouver Island from Chatham Point at its east end to Blinkhorn Peninsula at its west end, a distance of about 54 M.[5] West Cracroft Island forms the north shore at the western end of Johnstone Strait; Cracroft Point is at the western tip of the island. Boat Bay, on the south shore of the island, is some 6 M east of Cracroft Point. The channel in the vicinity of Boat Bay is 1.85 M wide. Boat Bay Light, with a nominal range of 10.7M and quick flash red (QR) characteristics, is obscured by high land northward of 102.[6] The light was functioning satisfactorily at the time of the grounding. 1.8 Main Engine Operation and Engine-Room Personnel Personnel were stationed in the engine-room and the main engine was on bridge control at the time of the occurrence. The engine was on 30-minute stand-by, and was available for immediate use in an emergency. 1.9 Visibility from the Bridge Neither the masts nor the gantry cranes interfered with the navigational visibility from the bridge. 1.10 Communication 1.10.1 Communication with Marine Communications and Traffic Services The vessel was operating in Johnstone Strait, a Vancouver Traffic Zone area for which MCTS has no radar coverage. Communications in the area are handled by the Comox MCTS centre. The very high frequency (VHF) designated frequency for the area is channel 71, and all conversations are recorded. As per the general practice, the pilot handled all communication with MCTS, communication that the OOW reportedly monitored but only casually when it came to reporting at call-in points. The RAVEN ARROW participated in the MCTS reporting system; the salient features of the recorded communication were as follows: 1.10.2 Shipboard Communication Communication between the pilot and the OOW was conducted in English. Communication respecting navigation of the vessel was minimal but there was no language barrier between them. 1.11 Navigation Equipment The vessel's navigation equipment included: Two radar sets, one X-band and one S-band, both fitted with automatic radar plotting aid (ARPA) capabilities. The information displayed on the radar included ship's heading, speed of the vessel, global positioning system (GPS) position, way point number, distance to go. The radar is fitted with auto-clutter, which will allow the clutter to automatically adjust to sea conditions; two GPS systems; a gyro compass with four repeaters; a course recorder; a speed log, two depth sounders, and a GMDSS comprising two VHF digital select calling controllers and receivers, an MF digital select calling controller and receiver, and an HF radio system; and British Admiralty (BA) chart No. 3387 (in use at the time of the grounding). No equipment malfunction was reported. 1.12 Navigation with Pilot on Board Compulsory pilotage areas have been established by pilotage authorities to ensure safe and efficient navigation of vessels in Canadian waters where local knowledge is essential. For the west coast of Canada, these areas have been defined in the Pacific Pilotage Regulations. The RAVEN ARROW was in compulsory pilotage waters when she grounded. Under the Pilotage Act, a licensed pilot who has the conduct of a ship is responsible to the master for the safe navigation of the ship.[7] 1.12.1 Established Navigational Practices The STCW 1978 as amended in 1995, the IMO Code of Nautical Procedures and Practices,[8] the Bridge Procedures Guide by the International Chamber of Shipping and established navigational practices all emphasize that: the master and/or the OOW must cooperate closely with the pilot and maintain an accurate check of the ship's position and movement; the pilot's presence on board does not relieve the master and the OOW from their duties and obligations for the safety of the ship; and if in any doubt as to the pilot's actions or intentions, the OOW must seek clarification from the pilot and, if doubt still exists, notify the master immediately and take whatever action is necessary before the master arrives. 1.12.2 Navigational Practices on the RAVEN ARROW The master's standing orders included the following: All Rules of the Road to be strictly observed. Do not hesitate to use whistle/engines/helm as and when required. Pilot's presence on the bridge does not relieve the OOW of his duties; and that the OOW [should] plot vessel's position every 15 minutes. OOW shall, at all times, execute and monitor the passage plan. Call the master at any time the OOW is in doubt, or if visibility deteriorates to three miles or less. 1.13 Conduct of Navigation 1.13.1 Use of Course Book During the transit, the OOW plotted the vessel's position at about 15-minute intervals, on the chart in use. The pilot did not refer to those positions nor did he refer to the chart to refresh his memory. The pilot carried a personal course book, which he used to facilitate his navigation of the vessel. Included in the course book was a sequential listing of courses to steer, distances between course-alteration positions, reference to navigational aids, and pilotage remarks. The course book had no provision for the recording of ETA or the actual time of course alteration, nor was the pilot keeping any other record of the vessel's progress. The pilot had to rely solely on his memory to keep track of the vessel's position. 1.13.2 Method of Navigation and Monitoring Vessel's Progress The pilot referred only to the radar to monitor the vessel's progress whereas, on this watch, the OOW used the GPS (except for the 0130 position, which was taken from the radar). Also, on this watch neither the pilot nor the OOW made a practice of using more than one method of monitoring the vessel's position. A review of the course recorder trace revealed the following: According to the OOW, shortly before 0130 he asked the pilot to confirm that 0800 was the vessel's ETA at Pine Island (a prominent position further down the vessel's track at the entrance to Queen Charlotte Sound). This drew a response from the pilot to the effect that he hoped the vessel had not overshot the alter-course position. After they both checked the radar display, the OOW sought confirmation from the pilot that the vessel had reached alteration point, to which the pilot responded in the affirmative. The OOW took a range and bearing of a point of land and noted these values on the chart. Before the OOW had time to plot the vessel's position on the chart, the pilot began a course alteration. The OOW returned to the conning position and ensured that the pilot's orders were promptly executed by the helmsman. The vessel's position was plotted on the chart following grounding. 1.14 Bridge Resource Management (BMR) The essence of BRM is the effective utilization of all available resources to ensure the safe completion of the operation. BRM addresses the management of attention, operational tasks, stress, attitudes, and risk. BRM recognizes that there are multiple determinants of mission effectiveness and safety, such as individual, organizational, and regulatory factors. Optimizing the management of these elements will have a direct effect on four factors critical to the successful outcome of any operation, namely, recognizing and defining the nature of the problem encountered (situational awareness); reflecting on and regulating one's own judgements or decisions (metacognition); involvement of others in the problem solving (shared mental models); and understanding what must be done, in what priority, and what resources are required and available (resource management). There are several key areas that are addressed in successful BRM programs. These include team building and maintenance, communication processes and decision making, workload management and situational awareness. 1.14.1 Team Building and Maintenance While the characteristics of individual team members are important, a team--in contrast to an individual--can share work, perform a task in a more timely and effective way, and achieve a higher level of performance than could the best individual working alone. Research has demonstrated that there is a formation process for teams during which patterns of communication and interaction are established.[10] Once established, the process continues and leads to activities that can maintain patterns of effective (or ineffective) group communication. 1.14.2 Communication Processes and Crew Decision Making Crew decision making is managed decision making. The pilot is responsible for making the decisions but is supported by input from the crew, both on the bridge and from shore (e.g., traffic control). This requires a group climate that encourages participation and the exchange of information. Poor communication can result in crews not sharing a common understanding of a situation, or in a misunderstanding of the pilot's intentions. 1.14.3 Workload Management The tasks essential for safe navigation of the vessel are allocated to different persons best equipped/experienced to carry them out so that no members of the bridge team, including the pilot, carry a workload that is beyond their capabilities to handle. 1.14.4 Situational Awareness Situational awareness is the accurate perception of the factors and conditions that affect a vessel and crew during a defined period of time.[11] More simply stated, it is knowing what is going on around you. At the level of the individual, situational awareness can be thought of as the mental model that an individual has of a given situation and time. Mental models develop from cues in the immediate situation and environment, e.g., location, speed, presence of hazard, as well as information from education, training and experience. In the absence of a complete set of cues for a given situation, fragmentary information is sometimes combined with mental expectations and integrated into the mental model. A bridge team, a well-defined group of individuals, combines to create a unique blend of personalities, attitudes and shared responsibilities. They include the people that constitute the group and the operational structure in which they function. As the mental models of each member of the group will vary, so each may have a unique awareness of the situation. The safety of the voyage depends upon the level of situational awareness that the group is able to attain together and is limited by the situational awareness of the individual who has the conduct of the vessel, in this case the pilot. A fundamental factor in maintaining optimal situational awareness is the ease and effectiveness of communication. The ideal working environment includes a situation where: the pilot encourages a climate in which bridge team members can comfortably provide inputs and there is an expectation that the input will be considered; each member of the bridge team does everything feasible to support the pilot to maximize the latter's level of situational awareness; and the pilot recognizes the contribution that each member of the bridge team can make to the group and objectively considers input from those who exhibit competency in the navigation task at hand, recognizing the individual's area of expertise. 1.15 BRM Training The Board, concerned that the lack of BRM training among pilots and ships' officers increases the chances for accidents in compulsory pilotage waters, recommended to Transport Canada (TC) that BRM training be made a prerequisite to the granting/renewal of proficiency certificates/pilotage licenses.[12] In response to the recommendations, Transport Canada Marine Safety (TCMS), in consultation with industry representatives, was in the process of finalizing a BRM training syllabus. At the time of this occurrence BRM courses were not mandatory. However, TCMS encourages shipping companies to take the initiative in implementing BRM concepts on their vessels. Recognizing the international scope of the marine industry, the Board further recommended that TC use the IMO forum to promote international support for the provision of formal BRM training requirements worldwide.[13] The IMO (through the STCW Convention 1978, as amended in 1995, Chapter VIII, Part3-1 of the non-mandatory Code B) provides guidance on keeping a navigational watch, and suggests that shipping companies take the initiative in implementing BRM concepts on their vessels. 1.16 BRM Application 1.16.1 Master-Pilot Exchange of Information On boarding, the pilots were presented with a pilot information card and the exchange of information included the following: the vessel's forward and aft draughts; engine manoeuvring speeds data; vessel manoeuvring data; and advice that the navigational equipment and main engine were functioning satisfactorily. 1.16.2 Working Relationships--Pilots and Ship's Personnel The rapport among master, pilots and OOW on the RAVEN ARROW was good. The master and the OOW had confidence in the pilots, and the performance of the pilots was never an issue. Investigation also revealed that the pilots sometimes encounter a ship's complement who lack communication skills in English, who take a passive approach to navigation with a pilot on board, and who have been subjected to a heavy workload when the vessel is on the coast. The pilots indicated that these factors can, and in some instances did, lead to them taking on the full workload. 1.16.3 Passage Planning and Pilotage There were only minor differences between the courses laid by the ship's complement and those contained in the pilot's course book for the area covering Fanny Island to Cracroft Point. However, there was a significant difference in the plan to round Cracroft Point. On the vessel's proposed route an alteration of some 70 degrees was required, whereas the pilot intended to make two alterations, of some 30 degrees and 40 degrees respectively, over a mile apart (see Figure 2). The pilot had not informed the OOW of this plan nor had he indicated to the OOW the minimum safe distance from the shore he intended to keep. According to the International Chamber of Shipping Bridge Procedures Guide, information, which may include courses to steer, headings, leading lines, parallel index distances, distances between way points, and important navigational marks that would be used to identify major course alteration points, should be presented on a suitable chart or a chart sketch in a format that can be accommodated at the conning position or radar display. There was no such plan aboard the RAVEN ARROW. The Board has been concerned that the lack of an appropriate exchange of information on a pilot's intended passage precludes effective monitoring--by the ship's officers--of a vessel's progress in compulsory pilotage waters and increases the chances of accidents, e.g., grounding/striking, in the ecologically sensitive marine environment. Accordingly, the Board has recommended that: The Department of Transport require that pilots, as part of their initial hand-over briefing: obtain the master's agreement to the intended passage plan; and invite the bridge team's support by having the officer of the watch plot and monitor the vessel's position at regular intervals and report the position to the pilot with respect to the agreed passage plan.[14] In response to the recommendation, the TSB was advised that TC and the pilotage authorities will promote procedures that clarify the understanding of the pilot and ship's officers as to the passage to be undertaken and their respective obligations in ensuring its successful completion. Reportedly, the institution of safe corridors is currently being considered as one of the alternatives to address this issue. The International Maritime Pilots' Association also recognizes that effective communication and information exchange, and a general agreement on plans and procedures for the anticipated pilotage passage (with the understanding that the passage plan is a basic indication of the pilot's preferred intention) are essential elements for effective pilotage.[15] 1.16.4 BRM During Voyage In this instance, pilot No.1 had received BRM training but did not opt to use the services of the OOW to advantage in the navigation of the vessel because the latter was new to the area and the vessel. However, during the 1300-1600 watch, September 23, the second officer, who was the OOW with pilot No.1, had observed that the vessel was north of the course as laid on the chart for the vessel in the Strait of Georgia. The OOW requested routing information from the pilot and was informed that the vessel would be taking the alternative route via Sabine Channel. During the 0000-0400 watch, September 24, in conversation with the OOW, the pilot had remarked on the similarity between the courses pre-plotted on the chart and those he would normally take in that area. 1.17 Pilot Scheduling Since 1996 the pilotage company has employed a total of 112 pilots--including 10 seasonal pilots and 2 half-time pilots--to meet the pilotage demands. The seasonal pilots work full time during the peak season and half time during the slack season and have a minimum of eight years' experience. The half-time pilots work half time throughout the year and have a minimum of 15 years' experience. The current scheduling system was designed and implemented prior to the cruise ship boom of recent years. 1.17.1 British Columbia Coast Pilots (BCCP) Scheduling System Following BCCP policy, the basic building block of a pilot's schedule (with some modification) consists of 20 days on duty followed by 10 days off duty, with a pilot receiving an extended leave upon completion of the third consecutive work cycle (80-day block). In any given year, pilots receive a total of three extended leave periods, two of which are about 30 days long, and the other about 50 days (see Table 2). The pilots have a four-year scheduling cycle, which ensures equitable rotation of duty periods and extended rest periods over the slow and peak traffic seasons. 1.17.2 Pilotage Assignments During the peak season, from mid-May to the end of September, the pilots have a full workload during their 20-day on-duty period.[16] They carry out between 14 and 21 assignments in the 20-day cycle; on average, between 14 and 17 assignments, most of which are long trips.[17] In the rest of the year, the pilots average 10 to 12 assignments in the same period, most of which are short trips. BCCP has received complaints from some pilots that they tend to become fatigued towards the end of their 80-day cycle during the periods of increased workload associated with the peak season. 1.17.3 Pilot's Recent Assignments Pilot No.1 was near the end of his 80-day cycle at the time of the occurrence and was scheduled to proceed on leave fromSeptember 27 to October 27. His most recent assignments, from September 18 to the time of the occurrence, were as follows: The information as recorded by the pilot shows that he had five hours of sleep between 0700 and 1200 during his back-to-back assignments on ASIA STAR. No other sleep was recorded. 1.17.4 Pilot Work/Rest Allowances and Call-backs The Agreement between the PPA and the BCCP states, in part, that . . . the Company [BCCP] will assure that an adequate work force will be provided to handle the normal workload. It also lays out the minimum rest period of eight hours following any assignment (excluding short trips), with an additional allowance for travel time. 1.17.5 Pilot Watches There is no set standard for pilot watches. They vary from vessel to vessel and are arrived at by mutual consent between pilots. Some prefer a six hours on/off watch schedule while others prefer a five hours on/off schedule. Aboard this vessel, the pilots worked a five hours on/off schedule, with the last segment to be equally shared between them. Pilot No. 1 was on watch from 1300-1800. After having his dinner, he returned to the bridge at about 1900 to watch traffic off Cape Mudge. While on the bridge, pilot No. 2 observed that pilot No. 1 looked tired, that he leaned over with his head bowed, was less talkative and that his speech was slow. At about 2130 pilot No. 1 returned to his cabin, where he lay down. It was the intention of pilotNo. 2 to allow pilot No. 1 to obtain additional sleep. However, at about 2240 pilot No. 1 was called to the bridge for his tour of duty, where he arrived at 2300. 1.17.6 Sleep History Pilot No. 1 indicated that he has no problem sleeping. He went to bed at 2200, September 22, the night before the RAVEN ARROW assignment, and woke up the following morning at 0600 having had what he considered to be a satisfactory night's sleep. While aboard the RAVEN ARROW, the pilot had lain down for about an hour to an hour and a half but did not sleep during the entire period. At the time of the occurrence, the pilot had been awake for over 19.5hours and would have been required to be on watch for a further 1.5 hours. 1.18 Officer of the Watch (OOW) Work/Rest History During the 72 hours prior to the occurrence, the OOW's work/rest periods were as follows: According to the OOW, he slept well on the night of September 23 and was well rested before his watch on the morning of September 24. 1.19 Demand for Pilotage Service Over the last three years there has been a steady increase in the number of foreign vessels calling at west coast ports and/or transiting the west coast pilotage waters, the result of which has been an increase in coastal pilot assignments. This period has also seen a boom in cruise ship operations. The summary of annual pilotage assignments for the west coast is as follows: 1.19.1 Pilotage Characteristics--Pacific Region A review of the 1996 statistics for pilotage assignments revealed the following:[19] The assignments varied from a minimum of 854 trips in January to a maximum of 1,152 in August. The busiest 30-day period was from July 24 to August 23, with 1,309 trips, 157 trips more than the busiest calendar month. The least busy 30-day period was from March 9 to April 8, with 839 recorded trips, 15 trips fewer than the least busy month. 1.19.2 Call-backs The seasonal peak demand for pilotage services results in pilots who, although scheduled to be off duty or on their extended leave periods, are recalled to handle assignments. The BCCP makes every effort to recall first those pilots who are on their extended leave periods. If none are available--as is often the case--pilots on their 10 days' off-duty period are called. Generally pilots receive between 6 and 12 hours' notice for a call-back assignment; however, sometimes, the notice period can be as short as 2 or 3 hours. Individually, each pilot has the option to take or to refuse any particular additional assignment, but the (pilot) population as a whole is contractually obligated to handle these assignments. The pilot who undertakes these assignments is compensated with future time off, to be taken at any time, which may include the peak season. 1.20 Pilot Work Environment and Safety The work environment of pilots requires them to work irregular schedules that are sometimes demanding and involve work in adverse weather conditions. Currently, while some information is disseminated to pilots by the BCCP, there is no formal training program in place to help pilots better mitigate the adverse effects of irregular work schedules on their performance. The lack of such training across all pilotage authorities is an ongoing concern for the Board. Given the vulnerability of individuals (in safety-sensitive positions) to significant errors in judgement when fatigued, and given that many factors are controllable by the pilots themselves (in terms of personal lifestyle modifications), the Board recommended that: The Great Lakes Pilotage Authority [GLPA] develop and implement an awareness program to provide guidance to dispatching staff and pilots on reducing the adverse effects of fatigue on job performance.[20] In response to the recommendation, the TSB was informed that the GLPA is committed to ensuring that all operational employees are provided with information to help them reduce the adverse effects of fatigue on job performance. Reference materials have been gathered from specialists in this field and distributed to the pilots. In early 1998, the program was offered as part of pilot training curriculum, and no further courses are planned. In the last few years the BCCP and the pilots have become aware of fatigue-related issues through the in-house distribution of information. The BCCP is exploring the possibility of a formalized training programme to help pilots mitigate the adverse effects of an irregular work schedule on performance.